Acute Artery of Percheron Infarction: A Case Report Highlighting Diagnostic Challenges and Management

The Artery of Percheron (AOP) is a rare anatomical variant originating from the posterior cerebral artery to supply the bilateral paramedian thalamus and rostral midbrain. AOP infarcts are rare, present with variable symptoms, and are often not detected by conventional neuroimaging, which poses challenges for early diagnosis. This case study presents a 58-year-old male who presented with acute encephalopathy and a Glasgow Coma Scale score of 8. Initial imaging with CT and CTA was negative for an acute intracranial process. MRI revealed bilateral paramedian thalamic and left midbrain ischemia consistent with an AOP infarct. The patient was not a candidate for thrombolytics because his symptoms began nine hours prior to first medical contact, which falls outside of the 4.5-hour therapeutic window for thrombolytics. In addition, his negative CTA precluded his candidacy for thrombectomy. At the time of discharge, the patient's encephalopathy had improved, but he had residual dysphagia, unintelligible speech, and required assistance with his activities of daily living. This case underscores the diagnostic difficulty of AOP infarcts due to their atypical presentation and the limitations of early imaging modalities. The variability in clinical presentation necessitates a high index of suspicion, as well as the use of advanced imaging techniques, for a timely diagnosis. Very few patients are diagnosed within the therapeutic window for thrombolytics due to initially negative CT and CTAs. Early clinical suspicion should warrant MRI for diagnostic confirmation. Optimal management for patients who fail to meet criteria for thrombolytics, and endovascular intervention is challenging because there are no universally accepted guidelines for the management of AOP infarcts. Early recognition with MRI and tailored management are crucial for optimizing patient outcomes in cases of rare cerebrovascular anomalies.